Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, January 19, 2007

Give Peace a Chance

"Peace of mind." In the previous post, that's exactly (as a commenter pointed out) what the ad is all about: trying to create peace of mind as a new reason for having a defibrillator implanted. Get people to dread Sudden Cardiac Arrest, maybe they'll try to talk their doctors into the procedure, even as the typical cardiac indications don't exist. And, when you think about it, it could happen: Doc, if you don't give me one, and I die of cardiac arrest (don't we all, eventually?), I'll see to it that my family sues you for everything you have....

These ads, and many like them, are about creating a cure for a problem that doesn't exist -- at least not to the degree that the makers would like you to believe. Haven't heard much about "social anxiety disorder" for a while? Maybe it's because it turned out the acronym was already taken. (OK, I'm no psychiatrist: I'm sure the condition exists, or could well exist. But the ads clearly were trying to convince a big swath of the population that they have it. Hell, I may have it... Got a drug?)

Getting back to where I began: peace of mind is not a specious goal. Certainly, it's part of what physicians aim for in treating their patients: reassurance, satisfaction that a risk or disease is under control or being attended to properly. The concept comes up in my field in the form of "prophylactic surgery." Breast cancer is a case in point.

For women with a high-risk family history of breast cancer, and/or who carry one of the breast cancer genes, prophylactic mastectomy is a recognized option. And it's more than peace of mind: clearly in this context, it's cancer prevention. I've done it in several women, most often after a long relationship and a few biopsies, counseling about the options of careful followup and stating the degree to which, in an individual case, I'd be comfortable with it; and without reservations. But I wasn't sure what to do when Jane Doe requested it.

Jane was also a long-time patient. She had no significant family history, but her breasts were moderately lumpy and she had some fibrocystic changes. I'd done a few interventions over the years: open or needle biopsies, mainly. One day, she'd had enough. I knew it was very hard for her; she was frequently beside herself when she came to see me, whether it was for a routine checkup, or because of a lump she'd found. Yet as these things go, hers were far from the most difficult-to-examine breasts among my patients. I'd never felt uncomfortable in my ability to follow her along; in fact, as with many of my patients, I frequently avoided open biopsy when a lump felt benign to me, and a needle sample and mammogram were also bland. But Jane was a wreck much of the time, and on one visit she said she just wanted to be rid of her breasts: she couldn't sleep, she cried a lot, she worried about her kids. Her risk was not significantly elevated, I reassured her, and told her I felt we were on solid ground in the followup plan we'd established. It made no difference: she'd simply hit the wall. Peace of mind is what she craved, and bilateral mastectomy was the only way, she implored, she'd ever have it. Absent specific risk, was that a good enough reason?

I told her I wasn't entirely comfortable. In the back of my mind, thoughts flickered about being party to some form of self-abuse, of Munchausen syndrome, who knows? Again, I'm no shrink; I didn't have a name for it. But it was a concern -- facilitating a really big deal for the wrong reasons. Delicately, I told her before considering such a thing, I'd like to refer her for counseling: to see if there were other ways to deal with her anxieties (and, unspoken, seeking an answer to whether her concerns were due to some sort of thought disorder, or whatever a shrink might call it.) She wasn't delighted, but agreed.

The upshot was that the psychologist found Jane to be a generally well-grounded person, and felt there was no specific reason not to do the surgery, felt it was, in fact, reasonable. I was sympathetic to my patient, and after more meetings between us, I agreed to do the surgery. For peace of mind.

Well, it wasn't so easy: cancer-phobia is a recognized entity and has, I believe, its own diagnostic code. Trouble is, it's not on anybody's list of indications for mastectomy. Jane, and I, and my nurse all spent considerable time on the phone with her insurer. I wrote letters to their medical director, assuring him, among other things, that this was not an operation I undertook lightly; I'd not done it before for this reason. But Jane Doe was a special case, whose life had become miserable. I reviewed with him the psych evaluation. No sale; they resolutely refused to pay for it.

We worked it out: reduced fee, payment plan, doing the operation (bilateral simple mastectomy) as an outpatient to minimize cost. She recovered rapidly; soared, really. Neither she nor I ever regretted it. Still, I doubt everyone would agree I did the right thing.

7 comments:

It's too bad she had so much anxiety. There are so many ways to get cancer and you can't remove them all. I'm not sure that breast cancer "awareness" is so great if it just feeds anxiety.

I'm really glad Jane is doing well. It's really not so different from what those "Dr. 90210" patients describe; they pay out of pocket and are generally satisfied with the changes. Some people really do need surgery to feel okay...but OF COURSE you as a doctor don't want to hook up with some patient who really wants that leg amputation "just because". Those are the sickest of the sick, but it doesn't sound like cognitive or drug therapy helps them. Apparently they just mangle themselves in such a way that an E/R doctor is literally forced to give them what they want...kind of like "suicide by cop" in some ways.

But back to peace of mind...my sister got talked into one of those whole-body scans where they look for tumors. They turned up some kidney anomaly and she had to wait to see a specialist, imagining the worst. He told her it was nothing and that lots of people have it and never know about it unless they have a scan. My husband's grandfather was talked into one at age 98; I'm not sure what treatment he could have withstood if they found something. We're pretty sure that the mastectomy his grandmother had at 96 following her FIRST mammogram was the beginning of the end of her health.

I think doctors really need to address when a given patient should just "opt out" of screening. We just went through this with a relative who got a bad mammogram at 74--she is lucky to be alive after surviving a year in the hospital after a colonscopy puncture culminated in several surgeries and several more to address MRSA that she picked up. She's on a permanent trach at home and has been told she can never have another surgery because of her many respiratory problems and general medical frailty. But then I don't know if the screening was her idea (due to family history) or her doctor's.

Your post reminded me of a story by Hazrat Inayat Khan, about Job. I'm not sure how you feel about a somewhat religious slant being taken (and I apologize if this is the wrong place), but I think its beautiful, and I think its in agreement with what you did for your patient:

"There is a story about a prophet who was very ill. He suffered many years, and through his suffering his insight became clearer. His suffering was so great that those around him became tired of it and so, in order to relieve them from seeing his pain, he had to seek refuge with God in the forest. As his sight was keen and the ears of his heart were open, he heard from the trees, 'I am the medicine of your disease.' The prophet asked, 'Has the time of my cure come?' A voice answered: 'No.' So he said, 'Why shall I take you then?' Another time he had this experience again; he heard, 'I am the medicine of your disease,' and asked, 'Has the time of my cure come?' 'Yes.' The prophet said, 'Why shall I take you then?'

"When we think of this extreme ideal we may ask: is it not unpractical, especially at this time where there are so many treatments, so many mechanical means? But a thoughtful person will see how many people have ruined their lives by going from one treatment to another, lacking the patience and resignation in which resides their absolute cure. The remedy is not always the answer. It seems as if man becomes increasingly impatient every day owing to his superficial life; there is hardly any resignation to little things. Yet, it is better to resign than to struggle." -HIK, Volume 7, Part 2, Chapter 2

I have been in Torsades du pointes, and I've had cancer. If I got my choice I'd rather die from sudden cardiac death. That being said I can see how ads that promote preventing death could be alluring. Still,hard to see the allure of having a machine in your chest that could send electrical kicks to your heart.

I consider myself a smart and knowledgeable guy, more than most. Yet issues like this are not for anybody to second guess. Not me, not well-meaning friends, and certainly (and especially) not some drone in an insurance company whose only interest is profit for the company. It's between the doctor (assumed compassionate and diligent), the patient (assumed capable of rational thought), and whomever else they, and only they, deem potentially helpful. You did the right thing, given the particular circumstances. In fact, whatever you and she had decided, that would've been right. The only position the rest of us should have is to provide information if we happen to know something relevant, and otherwise to sit by, not meddle, and hope that whatever is decided it comes out good in the end.

Insurance companies are, to all appearances, uniformly scum. Someone I know needed breast reduction. She had two doctors (internists) arguing and writing letters on her behalf that it was a medically necessary procedure and had nothing whatever to do with "cosmetic" procedures or whatever the insurance drones were calling it. In the end she was forced to pay for it herself, since she, her doctors, and an excellent surgeon all agreed it was the best (and only) option. The surgeon was seriously steamed, but she was also unable to budge the insurance drones.

Here's something that will seriously improve the peace of mind of untold tens of millions: get rid of "managed care".

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.